Project Summary: Completion of the colorectal cancer (CRC) screening process, particularly follow-up of abnormal tests, results in detection of CRC at earlier stages. The process, which involves several steps and interfaces between patients, physicians, and clinic staff, is sub-optimal in the US, especially among under- and un-insured populations. These populations depend on safety-net clinical provider networks for their medical home, so safety-nets hold tremendous potential to reach out and deliver the CRC screening process to those needing it most. Safety-net patients' degree of social disadvantage (e.g., income, housing situation, social network & support) makes the screening process particularly challenging to complete. Little is known about how safety-nets address inadequate insurance and patient social disadvantage to overcome these challenges. Organizational factors such as culture, structure, and protocols may be key factors to improving CRC screening in safety-nets. This project uses qualitative methods (document analysis, participant observation, semi-structured interviews) and quantitative methods (EMR abstraction, hierarchical modeling) to elucidate organizational and patient factors associated with the CRC screening process in Parkland Health and Hospital System (Parkland), the integrated safety-net network for disadvantaged populations in Dallas County. The project has three specific aims: 1) Characterize the organizational factors at the network- and clinic-levels that influence guideline-based CRC screening process among patients in the safety-net network; 2) Characterize patient interactions with the safety-net network during the CRC screening process including those patients enrolled in Projects 1 and 2 of our PROSPR center; 3) Examine the effect of patients' degree of social disadvantage on completion of guideline-based CRC screening and follow-up and organizational factors (characterized in Aim 1) that may modify these relationships. This innovative mixed-methods approach will characterize best practices in CRC screening within a safety-net network. These findings will help address needs of disadvantaged populations and aid development of evidence-based interventions in the complex health care environment of disadvantaged populations.